CLASS AA CITATION -- PATIENT CARE
T22 DIV5 CH3 ART3-72311(a)(1)(A) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.
T22 DIV5 CH3 ART3-7231 1 (a)(1 )(8) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (8) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited.
T22 DIV5 CH3 ART3-72311 (a)(1 )(C) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.
T22 DIV5 CH3 ART3-72311 (a)(2) Nursing Service-General (a) Nursing service shall include, but not be limited to, the following : (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. The following reflects the findings of the California Department of Public Health during the Investigation of Complaint No. CA00196889 Inspection was limited to the specific complaint(s) investigated and does not represent the findings of a full inspection of the facility.
The facility failed to conduct an initial and ongoing comprehensive assessment of Patient A to address the patient's high risk for injury from a fall due to the patient's inability to ambulate without assistance and the patient's risk for hemorrhage due to the use of an anticoagulant medication and decreasing platelet and calcium levels. In addition, the facility failed to conduct an ongoing assessment of Patient A for potential contributing factors of the risk for falls such as bowel and bladder continence, short term memory loss, hearing and vision deficits, environmental factors such as the arrangement of the patient's room, and the patient's increasing need for independence.
The facility failed to develop a comprehensive plan of care for Patient A to prevent a fall and injury that included the identification of the increasing risk for injury and environmental hazards to prevent a fall and injury. In addition, following a fall, the facility failed to implement the intervention of an alarm to the patient's bed to alert staff to the patient's attempt to get out of bed unassisted.
On 7/30109 at 0440 hours, Patient A was found on the floor in her room at the foot of her bed. She was bleeding from the left side of her face. She had multiple bruised areas on the left side of her face and left arm, skin tears to the left chest and fingers bilaterally, and an abrasion to the left knee. When asked by staff, the patient stated she had needed to go to the bathroom. There was no documentation to show staff was alerted by an alarm when the patient exited the bed unassisted. Upon transfer to Hospital #1, the patient was diagnosed with a left subdural hematoma (bleeding over the surface of the brain). Within a few hours the patient became unconscious and non-responsive. Patient A died on 7/31 /09, from an expanding subdural hematoma.
On 7/30109 at 1515 hours, Patient A was observed at Hospital #1. The patient was lying in bed with a family member at her bedside. The patient was non-responsive She was observed to have a large bruised area to the left side of her face and a laceration which was oozing bloody drainage.
On 7/30/09 at 1535 hours, an interview was conducted with Patient A's family member at Hospital #1. The family member stated Patient A had been transferred to the facility about eight weeks ago for rehab. The family member stated he had attended a care conference at the facility on 7/28/09, regarding the patient. The family member stated he had to request the care conference be held. He stated the facility had not scheduled a meeting with him since the patient had been admitted. The family member stated the patient was told at the meeting she could increase the use of her walker for ambulation. The family member stated the patient had been living independently and was very active prior to her recent hip fracture. He stated she was anxious to improve and be discharged from the facility. The family member stated Patient A had fallen at the facility a few days prior to the care plan conference. When asked if the facility had discussed any plans to prevent further falls, the family member stated the fall was not discussed at the meeting . The family member stated he had been concerned last night (7/29/09) when Patient A called him about 1800 hours to say no one was answering her call light. The family member stated he was concerned because he knew her catheter (indwelling urinary drainage catheter) had been removed two days earlier. The family member stated he called the facility and the phone rang and rang before someone finally answered. The family member stated the facility had called him early this morning to tell him Patient A had tried to get up by herself and fell. He stated he was told the patient exited on the right side of the bed, away from the bathroom, and fell. The family member stated he had been told by the physicians at Hospital #1 that Patient A had sustained severe brain damage from a head injury from the fall and would not survive long .
Review of the health record for Patient A was initiated on 7/30/09. The patient was admitted to the facility from an acute care hospital on 6/3/09, with diagnoses which included status post repair of a left hip fracture secondary to a fall , chronic obstructive pulmonary disease, chronic kidney failure, and thrombocytopenia (low platelet count, which helps with clotting of the blood).
Review of the facility 's admission assessment dated 6/3/09, showed Patient A was continent of bladder and usually continent of bowel. The patient wore bilateral hearing aids and glasses. The fall/safety documentation showed the patient had fallen in the past 30 days, had balance and gait problems and needed assistance with transfers.
Review of the MOSs (Minimum Data Set) dated 6/13/09 and 7/22/09, showed the patient had short term memory problems and she was independent in the cognitive skills for daily decision making. The patient was assessed as incontinent of bowel and had an indwelling urinary drainage catheter in place due to urinary retention. The patient required extensive assistance from staff for mobility and transfers. The MDS dated 7/22/09, showed the patient had improved and required limited assistance from staff for ambulation in the room and hallways, but Patient A was unable to maintain her balance while standing without physical help.
Review of the physician's orders dated 6/6/09, showed Patient A was started on Coumadin (an anticoagulant) prophylactically due to the possibility of a post operative blood clot. Coumadin doses were titrated based on PT (prothrombin) and INR (international normalized ratio) laboratory results (tests used to determine the clotting tendency of blood).
Review of the plan of care for Patient A showed it was updated on 6/29/09. A care plan problem was developed to address Patient A's fall risks, fall history and preventative measures to be taken. Interventions/approaches listed showed the patient was at risk for falls; her bed was to be in the low position; the call light and bed controls were to be in reach; and the use of a bed mattress with bolsters for spatial orientation to prevent the patient from sliding from bed. There was no documentation to show the plan of care included an assessment of the patient's high risk for injury from a fall due to difficulty with balance, the use of anticoagulant medication , short term memory loss, and hearing or vision deficits.
On 7/26/09, Patient A experienced a fall from her wheelchair when she attempted to ambulate to the bathroom unassisted. The patient told staff she had wanted to go to the bathroom.
Review of the Interdisciplinary Progress Note dated 7/26/09 at 0930 hours, showed Patient A was found on the floor next to her wheelchair. Documentation showed the patient told staff members she stood up unassisted as she "wanted to go to the bathroom." Documentation showed injuries to the patient included skin tears to the right wrist, the right elbow, the left scapula, and the left shin. Multiple bruises were documented around the skin tears. The patient was assessed as alert and oriented with episodes of forgetfulness. The call light was within reach but was not used.
The lDT (interdisciplinary team) Review and Recommendation form dated 7/26/09, was reviewed. The area of the form "Reason for Review" was left blank. The area "lOT recommendations" showed documentation the patient's blood pressure was within normal limits; no pain issues and no pain medication had been given prior to the fall; the patient was improving in therapy; an indwelling urinary drainage catheter was in place; the first fall in the facility and interventions were in place, with escalation of interventions at the time of the fall. Documentation showed the use of a wheelchair alarm and a bed alarm would be implemented. There was no documentation by the lOT to show the patient's desire to use the bathroom, as her stated reason for getting out of the wheelchair unassisted, was addressed.
A care plan problem dated 7/26/09 was developed to address the patient's fall on 7/26/09. Interventions included encouraging the patient to call for assistance; using of an alarm on the bed and wheelchair; keeping the call light in reach of the patient and for staff to answer calls promptly.
Additional review of the physician's orders showed an order dated 7/27/09, to discontinue the indwelling urinary drainage catheter at 0600 hours on 7/28/09.
Review of the laboratory reports for Patient A revealed eGFR (estimated globular filtration rate (a test to determine kidney function) results ranging from 14 to 24.
According to the Core Curriculum for Nephrology Nursing, Fifth Edition, 2008, patients with GFR of 15-29 were classified as Stage IV chronic kidney disease. These patients would typically have laboratory abnormalities in several organ systems and usually begin to experience symptoms such as fatigue, anorexia, edema, apathy, impaired memory, and decreased cognitive function.
Laboratory report showed the patient had a decreasing calcium level on 7/20/09 from 7.1 mEq/dl to 5.9 mEq/dl on 7/27/09 (normal reference 8.6-10.3 mEq/dl).
According to Taber's Medical Dictionary, Edition 17, calcium is of great importance in blood coagulation.
Review of the laboratory reports for Patient A dated 6/5/09 through 7/16/09, showed variable levels of INR and PT levels were reported. Patient A reached the therapeutic level of 2.00 to 3.00, for only seven of the 14 INR reports. All of the PT results during this time period were above the reference bleeding time of 10.8 to 14.8 sec. On 7/24/09 , an INR level of 2.58 and a PT level of 31.2 sec were reported. The physician ordered Coumadin to be administered on 7/24, 7/25 , and 7/26/09. On 7/27/09, the INR level showed an elevated level of 3.91 and on 7/29/09 , the level was further elevated at 4.65. INR and PT levels were to be repeated on 7/31109, and no further Coumadin was ordered by the physician at that time.
According to Lexi-comp Online, a nationally recognized drug information site for healthcare professionals, the Federal Drug Administration has issued a Black Box Warning for Coumadin, noting additional concerns identified for elderly patients and their increased risk for bleeding. The warning states (in part): May cause major or fatal bleeding. Risk factors for bleeding include high intensity anticoagulation (INR >4), age (>65 years), variable INRs, history of GI bleeding, hypertension, cerebrovascular disease, serious heart disease, anemia, trauma, renal insufficiency. Patients must be instructed to report bleeding, accidents, or falls. The elderly may be more sensitive to anticoagulant therapy. Renal Impairment: No adjustment required, however, patients with renal failure have an increased risk of bleeding complications. Monitor closely. Special Geriatric Considerations: Before committing an elderly patient to long-term anticoagulation therapy, the risk for bleeding complications secondary to falls, drug interactions, living situation, and cognitive status should be considered. A risk of bleeding complications has been associated with increased age.
Patient A had a reduced kidney function and an increased risk for bleeding due to Coumadin therapy.
Laboratory reports showed the patient's platelet count was reported as 222,000 on admission to the facility (normal reference values for platelets are 140,000 to 440,000). On 6/17/09, the patient's platelet level had decreased to 166,000. On 7/16/09, the platelets had decreased to 103,000.
According to Taber's Medical Dictionary, Edition 17, platelets play an important role in blood coagulation. When a small vessel is injured , platelets adhere to each other and the edges of the injury, forming a plug to cover the area.
The combination of Patient A's decreased calcium level, decreased platelet count and increased IHR levels, created a very high probability of injury from bleeding should Patient A suffer a trauma such as a fall.
Review of the Interdisciplinary Progress Note for nursing dated July, 2009, showed consistent documentation on the night shift that Patient A was "alert with periods of confusion and forgetfulness."